beetrootCOMMUNITY enables safe prescribing of potentially toxic drugs and routine blood test monitoring (including PSA) for GPs. It either works with an existing beetrootDMARD installation in a secondary care environment or is run as Software as aService from our HSCN-hosted server. In either scenario we set up feeds of electronic copy of blood test results from local pathology laboratories for patients who need to be monitored. When those results are received they’re checked for abnormals or deteriorating trends. Patients’ records are also monitored to see if they’ve been for a blood test when expected (Did Not Attends).
In a shared care environment the monitoring of patients is usually shared between secondary care specialists and GPs. Initiation and titration of medication (and associated monitoring) is the responsibility of specialists. However once stabilised, responsibility for patients’ ongoing prescribing transfers to GPs.
Safe prescribing: many drugs like Disease Modifying Anti-Rheumatic Drugs (DMARDs) can have serious side effects and patients who take them should be regularly monitored. To prescribe these drugs safely it’s vital to know that a patient is stable by checking their recent blood results. This is known as safe prescribing. It may be difficult for GPs to know how stable patients are. That’s usually because they don’t have specialist knowledge as to what constitutes stability for patients on complex and possibly combination therapies.
Safe prescribing: collect electronic copy of blood test results and check them for abnormalities or deteriorating trends that may indicate instability. If a patient’s results are normal (they are stable) automatically produce an electronic certificate and send it to the relevant GP’s electronic patient record system to confirm it’s safe to prescribe. If any results are abnormal the certificate isn’t renewed and the abnormals are escalated to specialists for review. Certificates are time-limited. When the relevant GP needs to prescribe a simple check for a valid (in-date) certificate provides reassurance to go ahead with safe prescribing. This solution can be used with existing (or new) beetrootDMARD installations in secondary care, or independently.
beetrootCOMMUNITY case study – Towards Safer Shared Care
Towards Safer Shared Care (TSSC)
TSSC is a collaborative project between North Tyneside CCG, North of England Commissioning Support Unit (Medicines Optimisation) NECS and beetroot®. The project is commissioned by the CCG, and has been set up to alleviate North Tyneside GPs’ reluctance to re-prescribe potentially toxic immunomodulating drugs like Disease Modifying Anti Rheumatic Drugs (DMARDs).
The NECS medicines optimisation team under the leadership of Neil Frankland run a version of the blood test monitoring beetrootDMARD solution (called beetrootCOMMUNITY) to monitor patients prescribed IMDs and, if stable, create digital safe prescribing certificates which are sent to GP practices. When GPs come to re-prescribe drugs they simply check for the existence of a in-date safe prescribing certificate for the patient, and if one exists, can be confident their patient’s stability has been checked.
Neil Frankland describes the background to the project in more detail here*:
“Following a series of patient safety incidents, including an antibiotic interacting with an immune modifying drug (IMD), subject to shared care arrangements (SCA), an audit in North Tyneside CCG practices was undertaken by the NECS Medicines Optimisation team.
The audit’s aim was to understand the processes for the management of IMDs and identify failings in systems.
SCA in primary care is a paper-based communication system between secondary and primary care. It is recognised [i] the risk of prescribing specialist drugs in an unsafe manner is increased due to lack of functionality within GP electronic patient record (EPR) with systems heavily reliant upon other non-clinical staff to support the process. In many cases the next opportunity to resolve any problems only presents when a further prescription is requested.
The audit identified practices developed their own systems reliant upon human input at critical points to identify issues or undertake significant tasks. Numerous errors including knowledge and rules-based errors, omissions and action-based failures of skill such as technical slips or memory-based lapses were identified. Such errors have a high probability of reoccurrence mirroring the findings of an observational study.I The audit identified a signed SCA was absent from 17% of patients’ records.
The audit concluded primary and secondary care should preferably be integrally linked to improve communication, to mitigate the observed variation in practice develop a centralised monitoring team (CMT) to provide a consistent and more thorough approach. To address the lack of functionality in the EPR commission a digital risk management clinical decision support system (CDSS) to enable more robust monitoring and governance processes to improve safety.
The CCG commissioned beetrootCOMMUNITY a CDSS with functionality to ensure blood monitoring is undertaken, results are correctly interpreted to identify abnormals and deteriorating trends in line with BSR recommendations,[ii]provide assurance IMDs can be prescribed safely by creating a time sensitive digital certificate identifying the IMD is safe to prescribe, enable e-transfer and acceptance of SCAs to address the significant number of absent documents and enable them to be updated annually at specialist review.
The CDSS has the capability to capture blood results following patient enrolment possible from the point of IMD initiation by secondary care and in advance of SCA transfer. This would allow the early visibility so the CMT can update the EPR to ensure prescribing decision software can defend against inadvertent prescribed interacting medicines.
The CMT interact with the patient in the event of an abnormal result providing an opportunity to support the patient to understand their role in the SCA and their medication.”
[i] Narinder Chana, Talya Porat, Cate Whittlesea and Brendan Delaney Improving specialist drug prescribing in primary care using task and error analysis: an observational study Br J Gen Pract 2017; DOI: https://doi.org/10.3399/bjgp17X689389
[ii] BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs Jo Ledingham, Nicola Gullick, Katherine Irving, Rachel Gorodkin, Melissa Aris, Jean Burke, Patrick Gordon, Dimitrios Christidis, Sarah Galloway, Eranga Hayes: Rheumatology, Volume 56, Issue 6, June 2017, Pages 865–868, https://doi.org/10.1093/rheumatology/kew479
*extract from a paper submitted to the Clinical Pharmacy Congress, 2022 https://www.pharmacycongress.co.uk/